The
Achilles tendon has 2 major functions during running. The calf
muscles (1) lower the forefoot to the ground after heel strike;
and (2) raise the heel during "toeing off". Achilles
tendonitis is caused by a force on the tendon greater than its
inherent strength.

Most
runners land on their heels with their forefoot still 2 in from
the ground. Running fast and up and down hills places extra
force on the Achilles tendon. During downhill running,
the forefoot strikes the ground with greater force than on level
ground, since it drops further and has more distance to accelerate.
During uphill running, the heel is much lower than the
forefoot, so it takes a much greater force by the calf muscles
to raise the heel before toeing off.

A
soft heel counter allows excessive movement of the heel
in the shoe. The rear foot is not as stable and the Achilles
tendon has to pull on a wobbly insertion. This places uneven
force on the tendon and increases its chance of being torn.
Stiff-soled shoes that do not bend just behind the first
metatarsophalangeal joint place great stress on the Achilles
tendon just before toeing off.

Achilles
Tendon Injury At Its Insertion Onto The Heel Bone

The
tendon can be strained, or suffer a minor tear, at or close
to its point of insertion on the heel. Or the bursa between
the tendon and the upper part of the bone may become inflamed.
The condition may be complicated by small bony outgrowths (spurs)
forming on the heel bone. The spur sometimes becomes detached,
formed a focal point of pain.

The
pain usually comes on gradually, but it can be sudden. You feel
it tiptoeing or running, and the tendon feels tender over the
heel when you press on it. The cause is usually excessive use
of the calf in extreme ranges of movement, as, for instance,
when you run fast up a steep hill. Rough, protruding linings
in your shoes can also be a cause, producing bruising and tenderness
over the heel.

Specialist
treatment may consist of an injection, or physiotherapy treatment.
Your doctor may have X-rays taken, to make sure that there is
no damage to the heel bone, or spur formation. It may be necessary
to line the backs of your shoes with felt or padding, to create
a smooth surface. This injury is slow to heal, so you must rest
it.

Achilles
Tendon Injury Just Above The Heel Bone

The
tendon may become sore, thickened, and tender to touch at any
point up to about five centimeters above the top of the heel
bone. Some of its fibers may be torn or degenerated, while the
tendon's covering becomes thickened. The tendon feels stiff
first thing in the morning, and on starting exercise. When you
stand on your toes barefoot, the tendon hurts at first, but
then eases. However, it remains very sore to touch.

The
cause is almost invariably friction from shoes with high backs,
or heel-tabs. The first priority is to remove the cause: cut
down the heel-tabs with two vertical slits on either side of
where the tendon lies, to the level of the back of your ankle,
usually about five centimeters above the upper edge of the sole.
If there is no spasm causing pain higher up where the tendon
joins the calf muscle, you can safely resume running and sports
provided you warm-up and warm-down thoroughly. The tendon may
remain thickened and sore to touch for months, possibly years,
but provided you feel no pain during exercise, it is safe for
you to continue your sport.

Achilles
Tendon Rupture

This
may happen at any level in the tendon. A sudden severe pain
occurs, which often feels like a violent blow to the calf. Swelling
and bruising may appear, and the two broken ends of the tendon
often leave a visible gap. Usually, you fall at the moment of
injury, and walking is then too painful to try.

The
cause can be a blow to the muscle or tendon when they are tensed.
More often, the injury is caused by strenuous activity involving
the calf, such as sprinting or playing squash. The injury may
occur at the beginning of the activity, when the muscles are
'cold' and tight.

At
the moment of injury, it may not be clear whether the tendon
is completely torn. One test for this is to lie on your stomach,
and have someone squeeze the calf muscle bulk gently: if the
tendon is partly intact the foot will move to point downwards,
but if the tear is complete, the foot will remain still.

This
injury requires specialist treatment, which may consist of surgery,
to stitch the two tendons ends together, or immobilization in
a plaster cast, allowing the tendon to heal naturally. After
surgery, you can usually resume sport within three to four months.
If your leg is immobilized, the plaster will be on for eight
to twelve weeks, so, after rehabilitation, you will probably
resume sport about six months after the injury.

Foot
Injuries

Ligament
strains

The
many joints which comprise the foot are all bound together by
ligaments, or thickened protective parts of the joint coverings.
Any of these ligaments may be damaged by abnormal strains. Usually,
the strain is the result of a sudden twist. The strain may occur
gradually, from repeated over-stretching, if, for instance,
you wear unsuitable or unaccustomed shoes. In either case, once
a ligament is damaged, it will set up a painful spot which will
be aggravated each time you subsequently over-stretch that point,
or apply pressure over it. Even a tiny ligament can give severe
pain when strained, and the pain can persist for some months.

Treatment
may consist of an injection from your doctor; rest; supportive
strapping; underfoot supports to prevent stress over the damaged
ligament; or electrical and exercise therapy from a physiotherapist.
Any painful activities increase the damage and prolong the injury:
the more you can rest the foot, the quicker it recovers.

Plantar
Fasciitis

The
plantar fascia may be strained by a change in shoes. When the
fascia is strained, it usually becomes painful where the fascia
is attached to the heel bone, and the front of the heel bone
feels tender when you press it. The heel hurts on walking and
running, and on standing up after you have been sitting down.
It also hurts when the sole of your foot is put on the stretch,
for instance if you pull your foot and toes backwards towards
you with your hands. Specialist treatment may consist of an
injection and/or electrotherapy. A soft arch support will take
the pressure off the fascia. Painful activities should be avoided.
You can resume sport when the tenderness to pressure under the
heel has disappeared.

Metatarsalgia

This
is a general term to describe pain in the forefoot, between
the metatarsal heads. The pain may be associated with, or caused
by, structural defects such as an excessively high arch. Treatment
aims to correct the defects and improve overall foot function,
usually by exercises to improve the balanced working of all
the muscles in the food, and by foot supports to improve the
mechanical alignment of the joints.

Bunion

In
this condition, technically known as hallux valgus, the big
toe is pulled towards the second toe, causing the big toe joint
with the first metatarsal to form an angled protrusion on the
inner side of the foot. The condition is caused by excessive
pull inwards from the tendons acting on the toe. Shoes with
pointed toes can contribute to the problem. The deformity may
become severe, but it is not necessarily very painful. If it
does cause pain, pads are used around the protruding bone, to
try to prevent friction from shoes over it. Underfoot support,
to try to rebalance the weight-bearing load, may be tried. If
the joint becomes very painful, and especially if the second
toe is crushed by the sideways drift of the big toe, an operation
is needed to remove the protruding part of the bone and straighten
the joint.

Tenosynovitis

The
tendons over the top of the foot are vulnerable to this condition.
A direct blow, friction from tight shoelaces, or overuse strain,
can cause irritation between these tendons and their covering
sheaths. Over-stretching the tendons, by extending the ankle
and pointing your foot down, is painful. If you touch the tendons
and move your foot, you will feel a slight 'grating' sensation.
Specialist treatment may include an injection, or various forms
of physiotherapy treatment. You should check your shoes for
tightness over the mid-foot, hard lacing eyelets, or roughness
on the shoe tongues. If necessary, you should place a padding
along the whole tongue. Painful activities and over- stretching
should be avoided until the pain and grating have subsided.

Black
toenails

These
occur because of a direct blow to the nail, or through friction
from tight shoes, or from disruption of the nail, for instance
if an inner seam in a shoe catches on the toe and lifts the
nail away during movement. The blackness is blood and bruising
under the toenail. If the nail is painful, with a feeling of
excessive pressure, you can ease it by boring through the nail
with a sterilized needle, to release some of the blood. If the
nail is persistently painful, you should ask your doctor either
to treat it, or to refer you to a chiropodist or podiatrist
(foot specialist). You should take care to trim all your toenails
evenly, straight across the top of the toes, to avoid the further
problem of ingrown toenails.

Stress
Fractures

Runners
push off from their toes, putting great stress on the metatarsal
heads. The 1st metatarsal is usually immune to fracture because
it is much thicker and stronger than the others. The 5th metatarsal
is relatively immune because the major force of "toeing
off" comes from the first 2. The 2nd, 3rd and 4th metatarsals
are usually susceptible because of their thin diaphyses.

Symptoms,
Signs and Diagnosis
Patients usually present with forefoot pain, often during a
long or intense workout, which disappears within seconds of
stopping exercise. On successive exercising, the pain returns
earlier than previously, ultimately becoming so severe that
it may prohibit exercise and persist even with the patient lying
in bed. Palpating the swollen area causes pain at the facture
site. An x-ray usually is not sensitive enough to diagnose the
fracture until a callus forms 2 to 3 wk after the injury.

Treatment
includes stopping all sports that require running. Healing usually
takes 3 to 12 wk (it may take longer in elderly and in debilitated
patients). Women with recurrent stress fractures and oligomenorrhea
or amenorrhea may need to be treated with calcium, estrogen
and progesterone.

Shin
Splints

Anterolateral
Shin Splits

The
anterior compartment muscles (tibialis anterior, extensor hallucis
longus and extensor digitorum longus) hold the forefoot up during
foot descent and contract eccentrically immediately after the
heel strikes the ground. They are opposed by the much larger
gastronomies and soleus muscles, which pull the forefoot down.
The tremendous force of eccentric contractions can damage the
anterior compartment musclesSymptoms and Signs
Pain occurs in the anterior compartment muscles, at first only
immediately after the heel strikes the ground during running.
If running is continued, the pain will occur throughout each
step, eventually being felt constantly. By the time advice is
sought, there is usually severe point tenderness over the anterior
compartment muscles.Treatment
Treatment includes stopping running, trying an alternate exercise,
stretching the calf muscles, and doing exercises to strengthen
the anterior compartment muscles after they start to heal.

Posteromedial
Shin Splints

The
main function of the posteromedial compartment muscles is to
supinate the foot and raise and avert the heel just before "toeing
off". Increased traction on the muscles is caused by excessive
pronation and by running on banked tracks or crowned roads (exacerbated
by wearing shoes that do not effectively restrict pronation).
Excessive pronation causes the arch to drop lower than normal,
increasing the force necessary to lift the arch during supination.Symptoms, Signs and Diagnosis
Pain usually starts in the postremedial compartment muscles;
2 to 20 cm above the medial malleolus. It becomes more severe
when the athlete rises up on his toes or averts the foot. If
he continues running, the pain then moves forward to involve
the medial aspect of the tibia, and can then move up the medial
side of the tibia, to reach within 5 to 10 cm of the knee.
Pain location and severity depend on injury progression. First,
there is a tendonitis of the muscles of the deep posterior compartment.
If the athlete continues to run, the pain may progress into
the muscle bodies themselves; then traction on the tibialis
posterior tendon can lift the muscle from its bony origin, causing
subperiosteal hemorrhage and periostitis. With continued traction,
part of the tibia can be torn away.Treatment
Treatment is to stop running, until it causes no pain, choose
an alternate exercise, wear shoes with rigid heel counters and
special arch supports to limit pronation, avoid future running
on banked tracks and crowned roads, and strengthen the injured
posteromedial muscles.

Hamstring

Acute
injury

An
acute hamstring injury can happen in a variety of different
ways, with the one common factor that there is a sudden pain
in the muscles, which is directly related to a particular movement
or incident.

The
hamstring muscles or their tendons may tear as a result of an
over-stretch injury, for instance if you have to sprint suddenly
when you are cold, or when your muscles are tightened because
of a previous strain, or fatigue from training hard the previous
day. Over-stretching may happen if your foot slips forward when
your leg is straight in front of you, for instance as you land
during hurdling. A direct blow to the hamstrings while they
are contracting can tear the muscles. You may be hit by a hockey
ball or a squash racket while you are running fast. Inefficient
muscle function can also contribute to sudden tears in the hamstrings.

What
you feel is a sudden pain in the hamstrings, which may be no
more than a twinge, up to a searing pain. You may see bruising,
immediately, or some time after the injury has happened, and
the bruising, with perhaps swelling, will tend to track downwards
towards the knee. If there is a severe tear, you may see a knot
of tissue forming a bump on the thigh, especially if you work
the hamstrings by trying to bend your knee. After the initial
pain, the torn part feels sore to touch, and gives pain in the
same area whenever you contract the hamstrings, either by extending
your hip or bending your knee; and when you stretch the muscles,
by keeping your leg straight and bending forwards at the hips.

A
severe tear, involving a lot of muscle tissue, may need to be
stitched together again by a specialist surgeon. However, if
the tear is more minor, your doctor may decide that you need
no more than a conventional rehabilitation program, which you
must follow completely.

A
gradual pain in the hamstrings, directly related to a particular
movement or activity, is usually termed a hamstring 'pull' or
'strain'. This injury happens for similar reasons to the acute
tear. The muscles are tight, fatigued, or weakened, and are
then strained by overwork. Over training, especially if this
involves repetitive movements, is a common cause of hamstring
overuse strains.

By
definition, the overuse strain starts with only a very slight
pain, which gradually gets worse, as you continue with the activity
which caused the problem. Occasionally, the pain is only evident
when you work the hamstrings against resistance in their least
efficient range, lying on your stomach with your knee held bent
to a right angle, and extending your leg backwards at the hip.

The
problem with overuse injuries to the hamstring is that they
tend to recur. Even if they do not develop to the stage of an
acute tear, they limit your ability to run, sprint, hop, and
stretch your leg out. Specialist treatment may include injections,
and various forms of physiotherapy. But the most important factor
in recovery is regaining full flexibility in the muscles, and
efficient function. If you try to resume your sport before you
have completed the whole recovery process, you are making a
recurrence of the problems inevitable.

A
mild hamstring injury may recover within ten days to two weeks,
but a more severe problem can last for over three months. If
your hamstring injury does not improve, despite careful rehabilitation,
it may be that there is an underlying problem. Hamstring pain
and spasm can be caused by a stress fracture in the thighbone.

Heatstroke

Exposure
to high ambient temperature may lead either to excessive fluid
loss and dehypovolemic shock (heat exhaustion) or to failure
of heat mechanisms and dangerous hyper pyrexia (heatstroke)

Common
sense is the best preventive; strenuous exertion in a very hot
environment and insulating clothing should be avoided, and an
adequate fluid intake is important.

Heatstroke
(Sunstroke)

An
abrupt onset is sometimes preceded by prodromal headache, vertigo,
and fatigue. Sweating is usually but not always decreased, and
the skin is hot, flushed, and usually dry. The pulse rate increases
rapidly and may reach 160; respirations usually increase, but
the blood pressure is seldom affected. Disorientation may briefly
precede unconsciousness or convulsions. The temperature climbs
rapidly to 41C and the patient feels as if burning up. Circulatory
collapse may precede death; after hours of extreme hyperpyrexia,
survivors are likely to have permanent brain damage.

Old
age, debility, or alcoholism worsens the prognosis.

Heroic
treatment measures must be instituted immediately. If distant
from a hospital, the patient should be wrapped in wet bedding
or clothing, immersed in a lake or stream. The temperature should
be taken every 10 minutes and not allowed to fall below 38C
to avoid converting hyperpyrexia to hypothermia.

The
patient should be taken to hospital as soon as possible after
the emergency methods have been instituted for further management.

Bed
rest is desirable for a few days after severe heatstroke, and
temperature liability may be expected for weeks.

Heat
Exhaustion

Because
of excessive fluid loss, this disorder gives adequate warning
by increasing fatigue, weakness, anxiety, and drenching sweats,
leading to circulatory collapse with slow thready pulse; low
or imperceptible BP; cold, pale, clammy skin; and disorientation
followed by a shock-like unconsciousness.

Syncope
(faint) is a mild form of heat exhaustion and is precipitated
by standing or a long time in a hot environment, e.g. the soldier
on the parade ground, and is due to pooling of blood in the
heat-dilated vessels of the lower extremities.

Heat
exhaustion is more difficult to diagnose than heatstroke, but
its prognosis is far better unless circulatory failure is prolonged.

Treatment
is aimed at restoring normal blood volumes and improving brain
perfusion, thus the patient should be placed flat or with their
head slightly down. When they start responding, small amounts
of sugar water should be given.

Knee
Injuries

The
knee is not simply a hinge joint: you bend and straighten it,
but you can also turn it slightly in a twisting movement, when
the knee is bent. This rotary movement automatically accompanies
the bending and straightening movements. As you bend your knee,
the shinbone turns inwards slightly relative to the thigh bone.
As you straighten, the shinbone rotates outwards. You can only
rotate the knee actively and voluntarily when the knee is bent.
When you bend your knee against gravity or a resistance, the
muscles at the back of the knee contracts to perform the movement.
The hamstrings do the main work of bending the knee, but the
gastrocnemius tendons help, especially if the movement takes
place against a strong resistance. When you straighten your
knee in the direction of gravity, for instance while you are
lying on your stomach, the hamstrings pay out to control the
movement. The quadriceps muscles on the front of the thigh straighten
your knee against gravity or a resistance, but they also act
to control the movement, when the knee bends in the direction
of gravity's influence.

The
structure of the knee-joint has two effects. Firstly, the knee
is a very stable joint, by virtue of its strong binding ligaments
and the protective effect of the muscles which control the joint's
movements. Secondly, the joint has quite a wide freedom of movement,
because the bones are not closely bound within their own configuration.
The knee is one of the three major joints in the leg which transmit
loading forces between one's body and the ground. Its stability
helps to keep us upright on our feet when we are standing, walking,
hopping or jumping.

Knee
Pain
This can arise from various causes. The knee can be affected
by a spontaneous inflammatory arthritis. Or it can be one of
many joints involved in a multiple inflammatory arthritis. Pain
referred from the hip or back may be felt as a simple knee pain.
Problems in the thighbone may cause knee pain. In older age,
the knee, like the hip, may be affected by osteoarthritis, or
wear- and-tear degeneration. In children, unexplained knee pain
can be a sign of a very serious hip condition, the slipped epiphysis.

Knee
Swelling
Joint swelling is an important symptom in knee conditions. Because
of the complex and extensive synovial lining in the knee, the
joint may distend alarmingly, with swelling right round the
joint, reaching about seven centimeters above the knee onto
the front of the thigh. However, it can also be more subtle.
You may also see a small pocket of swelling, perhaps on one
or the other side of the joint; or there may be just a slight
puffiness on the front of the joint, on either side of the kneecap.
Swelling may occur at the back of the joint, without any visible
signs of it at the front. Joint swelling always indicates inflammation.
As in the ankle, knee swelling can be caused by gravity bringing
the fluid down from some higher tissues: the swelling may track
down from the hip joint or some part of the thigh muscles. However,
unlike the situation in the ankle, if you have persistent swelling
in the knee, which delineates the joint's shape, it is unlikely
to be gravitational swelling, and it is very likely to mean
that there is something wrong inside your knee.

If
the swelling has appeared for no obvious reason, it may indicate
that you have an inflammatory or degenerative condition. Your
doctor will probably arrange blood tests and X-rays, to decide
whether this is so. If the swelling occurs as the result of
an injury to the knee, and you are aware of having wrenched
it, or fallen on the joint, it is likely that you have damaged
one or more of the knee's internal structures, with irritation
or damage to the synovial lining. The swelling may come on at
the moment of injury, or some hours afterwards.

The
knee is very prone to injury, because of its mobility and the
variety of stresses we subject it to. The most common type of
traumatic injury to the knee is the twisting or wrenching injury.
This happens most frequently when your knee is bent, while carrying
your body-weight, and you twist awkwardly or unexpectedly. Skiers
and footballers are most susceptible to this type of injury,
but it can happen to you while walking or running, if you trip
and catch your foot, or fall while turning. Any of the knee's
structures may be damaged in this type of injury. The full extent
of the damage may be impossible to assess immediately after
the injury, and may only become evident when the knee subsequently
fails to recover its full function.

The
knee is also vulnerable to overuse injuries: gradual pains brought
on by an activity, which progressively get worse, if you continue
the activity. These are the injuries which must be distinguished
from the other, more serious, medical conditions which can cause
similar pain.

Frontal
Knee Pain

1)
Patellar Tendon Strain
The patellar tendon is very short, extending only between the
pointed lower end of the kneecap and the tibial tubercle, the
prominent bump of bone at the top of the shinbone. However,
it acts as the concentrating point for the pull exerted by the
quadriceps muscle group during knee movements, so it is an extremely
powerful tendon. The tendon works hard whenever the knee bends
and straightens under load. It works hardest when knee movements
involve a full bend under your body weight and gravity, for
instance if you do a full squat exercise in weightlifting, or
when you take off from one leg in high jumping or long jumping.
The tendon also generates a strong pull when you go up and down
stairs, when you run on hilly ground, and when you kick a football.

Because
the tendon plays such an important part in all movements at
the knee, it may be strained simply by overwork. This type of
overuse strain is usually due to a repetitive activity, such
as long-distance running, or extended sessions of hill running,
hopping and bounding, kicking, or squatting exercises. An overuses
strain is more likely to occur if the tendon is working inefficiently,
because it is fatigued through overwork, or tight due to cold
or previous excessive exercise. Bad shoes can contribute to
changing the tendon's angle of pull. This is especially true
if children and adolescents wear shoes with little support underfoot,
or high-heels, during their growth years. The tendon may also
be subject to sudden injury.

When
the patellar tendon is strained, a few of its many fibers may
be torn. This causes pain when you use the tendon, but it does
not necessarily stop the tendon from working through its normal
range of movement. As a result of a strain, or partial tear,
the tendon may become thickened, and tight, because of scar
tissue forming in the torn fibers. This limits the tendon's
function, and the tendon becomes more painful on movement.

The
tendon may tear completely, causing immediate functional disability.
When the tendon tears right through, the whole of the quadriceps
muscle group on the front of the thigh is incapacitated, as
its lower attachment point is destroyed. The kneecap rides upwards
over the thigh, as it is no longer held tethered over the front
of the knee-joint. There is of course severe pain, and it is
impossible to take weight through the leg. A normal patellar
tendon can only tear completely if a sudden enormous force is
applied to it. However, it may give way under less pressure,
if it has been previously weakened by repeated strains which
have made its center degenerate. Steroid injection into the
center of the tendon can result in severe weakening of the fibers.
Following inexpert injections to 'cure' a strain, the tendon
may tear under minimal pressure, for instance if you squat down,
or if you try to climb onto a higher step.

When
the patellar tendon tears completely, you must refer for specialized
treatment as a casualty. The tendon will have to be repaired
surgically, as quickly as possible after the accident. You will
not be able to put weight through your leg, and you should be
transported to hospital, keeping the leg as still as possible.

Osteochondritis,
a form of degeneration in a bone's growth point, can occur in
the lower part of the kneecap, where the patellar tendon attaches
to the bone. This complication is called Sinding- Larsen-Johnson
syndrome, and it causes severe pain when the tendon is stressed
during activity, as well as soreness if you press over the point
of the kneecap, or if you try to kneel on it.

2) Prepatellar
Bursitis ('Housemaid's Knee")
The front of the kneecap is protected by a fluid-filled pouch,
or bursa, which lies between the bone and its covering skin.
When the bursa is inflamed, it swells up, forming a large egg-like
protrusion over the kneecap. The condition is called 'housemaid's
knee', identified in women who had to kneel down constantly
to scrub floors and so were particularly prone to suffer from
it. The damaged the bursa has a cumulative effect from the repeated
pressure on the front of the knee. The bursa can easily be damaged
by a single hard blow on the kneecap, for instance if someone
kicks your knee, or if you fall onto your knees from a height.
The bursa may also swell because of a medical inflammatory condition.
Your doctor will be able to differentiate between the various
possible causes of the bursitis, if you can give him an accurate
account of exactly when and how it first occurred.

Although
the bursa may become large and unsightly, it is not necessarily
very painful or functionally disabling. It hurts when you press
it, and possibly when you stretch the skin on the front of the
knee, by bending your knee fully, or squatting down. If it does
become painful enough to interfere with your normal activities,
it will need specialized treatment. Your doctor may drain off
the extra fluid in the bursa, although the swelling may recur
after this is done. Otherwise, the bursa may be removed completely
by surgery to eliminate the problem and the possibility of recurrence.
After surgery, the knee is usually kept immobilized in a plaster,
to prevent a secondary bursa from forming in place of the original
one. About four weeks after the operation, the surgeon normally
allows rehabilitation to start, following removal of the plaster.

3) Knee-cap
dislocation
This is a problem which can occur at any age, but which often
happens to children. If it starts in pre-teen years, it tends
to be a continuing problem, with episodes that gradually get
worse over the years. Girls are particularly vulnerable to the
problem. When the dislocation is a continuing, chronic problem,
the episodes tend to be relatively mild, so that the dislocation
is hardly recognizable as such. However, in the older sportsman
especially, the dislocation can be severe, with the kneecap
remaining out of alignment until it is manipulated back into
place.

Specialist
care will aim to correct the mechanical defects that contribute
to, and are caused by, the kneecap dislocation. You will be
set a program of exercises to strengthen the inner part of the
quadriceps. If your foot mechanics have contributed to the weakness
in your knee, a podiatrist will make up special orthotic foot-supports
for you. If the dislocation problem is severe, you may be referred
to an orthopedic surgeon for an operation that would aim to
strengthen the kneecap from its inner side, and perhaps correct
the 'Q-angle' at the knee. In the worst of cases, the surgeon
may recommend removing the kneecap to eliminate the problem.

Pain
in the back of the knee

Popliteal
Bursitis
There are many bursea, or fluid-filled sacs for friction-free
movement, at the back of the knee.

Any
of these bursae may become inflamed and swollen. If an inflamed
bursae becomes very enlarged, it may push sideways into the
space at the back of the knee called the popliteal fossa. You
will then be able to see a defined, soft swelling protruding
from the back of the knee. It need not necessarily be very painful,
but by taking up space it may limit full movement at the knee.
You should refer to the doctor for an assessment of the swelling,
as this type of swelling can be disease-related. If it does
prove to be simply a bursitis caused by friction, perhaps because
you have changed your style in distance running, or changed
boats in rowing, it may not be necessary to have any treatment
for the swelling. The definitive cure is to have the swollen
sac removed surgically by an orthopedic surgeon. After surgery,
your knee is usually kept held still in plaster for some weeks,
after which you have to re-strengthen the muscles, and then
regain full movement.

Pain
inside the knee joint

Any
of the knee's internal tissues can be damaged by a severe injury,
but the cartilage (menisci) and the cruciate ligaments are those
most commonly harmed in sportsmen.

1) Cartilage
tears
The knee's soft-tissue cartilages can be damaged by pressure
from the bones of the joint when an abnormal force twists the
bones against each other unusually. In the normal way, the cartilages
move slightly, backwards and forwards, during knee movements.
In this way, the cartilages act as buffers throughout the whole
movement, although the joint surface of the thighbone is bigger
than the receiving surface on the shinbone. However, with abnormal
pressure, the cartilages may be jammed between the two bones:
if the bones then twist on each other and apply a shearing stress
on the cartilage, the tissue splits.

The
most common cause is an abnormal twist in your knee while your
weight is on the leg. In each case, your knee is bent at the
moment of injury. A sudden stress with the knee bent, even when
you are not standing on the leg, can be enough to tear the cartilage.
Cartilage tears can also be caused by a sudden over- stress
when your knee is straight, for instance if you miss a drop
kick in rugby.

This
injury gives instant pain, to the extent that you may not be
able to move the knee at all, let alone take weight through
your leg. Immediate swelling will inhibit movement further,
although the swelling may not appear until some hours later,
in which case the knee will feel weak rather than stiff in the
first instance. Visible swelling may extend right round the
knee, making the joint look bloated, or it may be only a small
patch, barely visible over the line of the joint. At the moment
of injury, it is impossible to tell, from the outside; exactly
how much damage has been done. First aid for the swollen knee
must be applied (see "treatment of acute sports injury").

The
only external sign that you might have torn a cartilage is the
so-called 'locked' knee. More often, the knee is too painful
to move immediately, and this 'locking' feeling only becomes
evident when the knee has recovered enough for you to be moving
it. Once you have applied first-aid measures and made the knee
comfortable, you must be taken for specialist help as quickly
as possible.

The
sooner an accurate assessment of the extent of the damage is
done; the better off you will be in the long-term. If you are
taken to a casualty department in a hospital, your knee will
probably be X-rayed, to see whether there is any bone damage.
You may also have arthrograms done, in which dye is injected
into your knee, so that soft-tissue damage shows up on X-ray.
You may even be admitted to hospital so that an orthopedic surgeon
can perform arthroscopy.

Once
a specialist has diagnosed a cartilage tear in the knee, there
are two possible courses of action. Either the torn part of
the cartilage must be removed surgically, or the problem must
be treated with rehabilitation only. The one certainty is that
the torn cartilage will not heal, or mend itself, naturally.
If the specialist decides on immediate surgery, it is because
he deems that the torn cartilage will create functional problems
in the knee.

The
cartilage removal operation is called a meniscectomy. Recovery
from the surgery can take a varying time, according to individual
circumstances. It is possible to be back to full sporting activities
within two weeks of removal of the cartilage through the arthroscope.

If
a specialist decides not to remove the torn cartilage, after
diagnosing the tear, it is because he believes that the damage
is slight, and the knee can recover functionally without any
need for surgery. Your leg may be immobilized in plaster, to
protect the knee, if the injury was severe; or you may simply
be given a supporting bandage to control the swelling.

In
either case, you must start straight-leg exercises immediately,
to maintain knee stability. You progress to gentle mobilizing
exercises to bend the knee as soon as your specialist allows,
when the knee is no longer acutely painful and swollen.

2) Cruciate
Ligament Tears
The cruciate ligaments are two strong bands that bind the shin-
bone to the thighbone, across the center of the knee. It takes
a strong force to damage them; they can be torn in a severe
twisting injury, for instance in a blocked kick or a sliding
fall in a tackle during football; or by excessive pressure forcing
the knee to 'bend backwards' when it is straight, for instance
if an opponent falls across your extended leg in rugby or hockey.

A
major shearing force can tear both cruciates together, usually
tearing one or both of the cartilages at the same time. A moderate
injury may tear one of the cruciates completely, without damaging
the second, and with or without accompanying cartilage damage.
At the moment of injury, it is totally impossible to assess
the extent of the internal damage through outward signs. The
only certainty is that, if your knee has swollen painfully,
some of its internal structures have been damaged. If you do
not have an accurate diagnosis at the time of injury, it may
only become apparent that the cruciate ligaments have been damaged
much later when you have started doing sport again. Then you
may find that in certain positions your knee feels loose and
instable. It may feel as though it is 'rolling' on itself, backwards
or forwards, usually giving a 'clunking' sound, with a sharp
pain. This makes running and turning difficult. This unstable
feeling is an external indication that there is some damage
to the cruciates. If your knee locks as well, then there is
also likely to be cartilage damage.

At
the moment of injury, the knee should be made comfortable in
applying the first-aid measures for the swollen knee. It is
essential to obtain a specialist opinion as quickly as possible.
If the surgeon finds that both cruciate ligaments are completely
torn, he will probably perform an immediate operation to try
to repair the damage. If there is partial damage to one or both
of the cruciates, the surgeon will choose whether to operate,
or whether to allow the knee to recover enough for you to resume
sport, and see whether there is any residual disability when
you use the knee.

Whether
the repair is done straight away, or after residual disability
has shown up, there are various methods that the surgeon may
choose to mend the damage. Some procedures involve mending the
cruciates themselves, either by re-attaching a torn end to the
bone from which it has snapped off, or by replacing the whole
ligament with a synthetic substance. Other methods of stabilizing
the knee involve tightening up the capsule and tissues around
the joint, to compensate for the internal instability. Whichever
method the surgeon chooses, rehabilitation is a slow process;
full recovery may take up to a year. It is vital to follow the
surgeon's rehabilitation program to the letter, as recovery
phases differ according to the particular operation done.

Knee
Surgery

The
knee joint is the most complicated joint in the body. It consists
of three joint surfaces that are covered with articular cartilage.
There are two menisci (cartilages) between the joint surfaces,
and four ligaments that stabilize the joint. When a person walks,
the load exerted on the knee joint is approximately four times
the body weight; with running it is eight times the body weight.

The
Clinical Examination

In
order to make an accurate diagnosis it is important to have
a complete medical history of the knee problem. This includes
the details of the mechanism of injury, the type and location
of the discomfort and symptoms such as swelling, giving way,
locking, etc. The medical history is followed by a careful clinical
examination of the joint, after which the surgeon should be
able to make a provisional diagnosis. This provisional diagnosis
is further confirmed by diagnostic tests.

Diagnostic
Tests

Routine
X-rays should show any abnormality in the bone itself and will
also show up wear and tear on the joint surface. It is, however,
not possible to see soft tissue structures such as cartilage
and ligaments on X-rays. In special cases MRI (magnetic resonant
imaging) is done, as this does show up soft tissue. An arthroscopic
examination can also help with the diagnosis.

The
Arthroscope

An
arthroscope is an instrument similar to a telescope. It is approximately
as thick as a pencil, and has a lens on the one end. The arthroscope
is placed into the joint through a small puncture wound. A small
video camera is attached to the back of the arthroscope, allowing
one to visualize the inside of the joint.

Arthroscopic
Surgery

This
is usually done on an outpatient basis. The patient would come
to the hospital on the day of the operation and be discharged
on the same day. No food or drink may be taken in for six hours
before the operation. On the morning of the operation, the patient
should report to the hospital reception, from where he or she
would be directed to the outpatient department.

Three
small puncture wounds are made in the joint while the patient
is under general anesthesia. The scope and other necessary instruments
are inserted into the joint through these wounds, and the necessary
procedure is performed. Surgical procedures such as the removal
of loose bodies, meniscectomies, repair of joint surfaces and
even ligament reconstructions can be performed through the scope.

In
most cases the patient will be able to take full weight on the
joint by the time he or she leaves the hospital. In a small
percentage of cases it might be necessary to use crutches for
a day or two.

REMEMBER:
One is not allowed to drive a car for the first 12 hours after
anesthesia.

Postoperative
Care

The
following should be observed after arthroscopic examination/surgery:

It
will usually be possible to walk without crutches. However,
if the joint causes discomfort, crutches should be used for
as long as necessary.

The
sutures are soluble and beneath the skin, and do not have
to be removed.

The
bandage around the joint can be removed after three days,
by which time the wounds should have healed to such an extent
that baths or showers would be possible.

If
the knee is pain-free after four weeks, it is not necessary
to make a follow-up appointment, unless the doctor has indicated
otherwise. It will be approximately four to six weeks before
the knee is completely pain-free.

The
doctor will be available to discuss any questions or problems.

There
are a number of exercises that could be done at home. The
exercise routine should be started as soon as the knee is
pain-free. If physiotherapy is indicated, the doctor will
prescribe it.

There
should not be severe discomfort. Light analgesics will be
prescribed, and they should control any pain. If there is
severe pain, swelling of the calf or any other problems, the
doctor should be contacted.